Are You Confident of the Diagnosis?

What you should be alert for in the history

Each year more than three million cases of child abuse are reported in the United States, resulting in over 2000 fatalities, and the numbers are only increasing.Of those abused, more than 66,000 were confirmed victims of sexual abuse.

It is very important to be able recognize abuse early since there is a 50% chance of recurrent abuse, which can result in severe injury or even death, upon returning to an abusive home. Dermatologists play a key role in diagnosis, since cutaneous injury is the most recognizable and common form of abuse. Dermatologists may be called upon to help distinguish skin conditions that mimic maltreatment from signs of intentional injury.

There are four types of abuse: neglect, physical abuse, sexual abuse and emotional/psychological abuse. Each type can have cutaneous manifestations. Among children confirmed by CPS agencies as being abused, an estimated 61% experienced neglect, 19% were physically abused, 10% were sexually abused and 5% were emotionally or psychologically abused. Many experts believe that sexual abuse is underreported because of victim fear, shame, and embarrassment. An estimated 1% of children experience some form of sexual abuse each year.

The history is one of the most important parts of the evaluation when abuse is considered. If the child is verbal, it is important to speak with the child away from the caregivers. Age-appropriate and simple, open-ended questions should be used such as “Tell me what happened to your leg?". The following questions should be answered during the interview:

Does the history of the injury match the presentation?

Is the history vague and lacking in detail?

Could the injury have occurred accidentally, based on the child's developmental and activity level?

Are conflicting histories given by different caretakers or family members?

Does the pattern of injury fit a biomechanical model of trauma that is considered abusive?

Was there a delay in seeking care for anything other than a minor injury?

Does the pattern of injury correspond to that inflicted by an instrument that would not occur through play?

Does the child have a history of repeated emergency department visits?

Does the child have a history of multiple injuries?

Is the child taking medication or does the child have a history of a bleeding disorder?

Is there injury to other organ systems?

The history is the gold standard for diagnosis of sexual abuse since only about 4% of children referred for medical evaluation have abnormal examinations. It is important for the interviewer to be familiar with childhood developmental milestones and age-appropriate sexual behaviors and knowledge.A sexually abused child is more likely to develop inappropriate sexual behaviors and age-inappropriate sexual knowledge. Presenting complaints may be nonspecific, such as sleep disturbance, phobias, enuresis and abdominal pain.

Physical abuse is one of the most frequently reported forms of child maltreatment, with traumatic skin lesions being the leading sign of abuse witnessed by physicians. Overall, children injured by abuse sustain more severe injuries and have worse survival and functional outcome than those with unintentional injuries.

BRUISES

Bruises are the most common type of injury in abused children. Ecchymoses are common in healthy and active children and therefore it can be challenging to distinguish inflicted bruises from those sustained accidentally. Location and pattern of the lesion help determine the etiology. Noninflicted bruising occurs in independently mobile children and is more commonly seen with walking than crawling. Such bruises are most often found on anterior bony prominences, such as the forehead and shins. On average, children typically have less than three accidental bruises that are less than 10 mm in size.

Characteristic findings on physical examination

Present in children less than 9 months of age who are not independently mobile (the likelihood of having a noninflicted bruise in a child not independently mobile is <1%)

Away from bony prominences

Multiple and clustered

Different stages of healing

Have a defined pattern (eg, carry the imprint of an implement)

Associated cutaneous and physical injuries

Sadly, a wide array of instruments have been used in child abuse that leave patterned imprints on the child's skin. Some implements of abuse include hands, knuckles or fists producing handprints or twist and pinch marks, belt buckles causing long bands of ecchymoses ,in a horseshoe-shaped mark, coat hangers, nails or hairbrushes producing linear excoriations and ropes, wires, or cords causing loop-shaped ecchymoses. The hand itself can leave a negative imprint when capillaries break between the fingers as blood is pushed away from the point of impact, leaving the outline of a hand.

Bite marks should be suspected when ecchymoses, abrasions or lacerations have an elliptical or ovoid pattern. They can be of particular concern because of their potential for infection. Bite marks typically have a central area of ecchymoses caused by either positive pressure from closing of the teeth with disruption of small vessels or negative pressure caused by suction. They are better visualized 2 to 3 days after injury because of decreased edema and surrounding erythema.

Human bites are typically superficial, whereas animals cause deep punctures or lacerations. When the dental imprint is clear, suspects' teeth can be molded and superimposed onto the photo of the victim's bite mark to help determine if there is a match. Adult bite marks can be differentiated from those of a child based a maxillary intercanine distance over 3cm.

Dermatologic mimics of ecchymoses must be taken into consideration during evaluation.

Abuse by burning comprises 6-20% of all child abuse cases. Burns to the skin can be electrical, chemical, thermal or radiant. Electrical burns are subtle and skin lesions may be inconspicuous or even absent. Acidic or alkaline chemical burns cause a prolonged period of injury because of residual product on the skin. Alkaline burns results in tissue liquefaction and deeper injury.

Characteristic findings on physical examination

Features of burns suggestive of abuse include:

Symmetrically distributed

Localized to the protected areas of skin such as the perineum, buttocks, posterior head or back

Characteristics of immersion

Require skin grafting or intensive care

Look older than the history suggests

Multiple and patterned

Associated with other injuries (eg bruises or fractures)

The most common mechanisms used to inflict injury include branding, cigarettes, and immersion in scalding water. As with bruises, the pattern of injury can help determine the type of instrument which was used to inflict trauma. Sadly, any hot medium can be used as an instrument of abuse, including common appliances such as hair dryers and irons. In branding burns, the imprint of a hot object is distinguished by uniform depth and clear margins. In comparison, only part of an object may be seen in nonintentional burns since the child withdraws from the pain.

Scalding is the most frequent form of abuse by burning, with 80% of injuries resulting from tap water.

Burns suggestive of immersion include:

Uniform depth and severity (eg, sharp line of demarcation between the normal and burned skin. In contrast, the burn dissipates as the liquid runs down the skin and cools in children who spill hot liquids)

Absence of splash marks (in contrast, they are present in an accidental injury when the child withdraws from the painful stimulus)

Stocking or glove distribution

Sparing of the flexural creases (occur when the child is forcibly submersed in a flexed position, causing a “zebra stripe” scald pattern. A “donut hole” like pattern can occur on the buttocks when the skin is pressed against the cooler surface of the bathtub. It is unlikely that severe buttock burns will occur in nonintential immersion, since diapers provide good protection)

Cigarettes are another very common implement of abuse and are often mistaken for bullous impetigo. Unlike cigarette burns, lesions of bullous impetigo tend to cluster superficially, respond quickly to antibiotics and rarely scar.

Features of cigarette burns:

Punched-out ulcerations of 8-10 mm

Randomly distributed

Nonexpanding dry base

Often scar

Multiple layer involvement of the skin leading to rolled appearing edges

Tend to exhibit features of third degree burns (eg, full-thickness and painless)

Unresponsive to antibiotics and heal slowly

There are a number of medical conditions that may produce skin findings, such as bullae, resembling burns.

Diagnosis confirmation

The differential diagnosis of burns in possible victims of child abuse includes:

Dermatitis herpetiformis

Bullous impetigo

Phytophotodermatitis

Bullous fixed drug eruption

Contact dermatitis

Epidermolysis bullosa

Staphlococcal scalded skin syndrome

Stevens-Johnson syndrome

Pemphigus vulgaris

Chronic bullous disease of childhood

Bullous pemhigoid

ALOPECIA

Characteristic findings on physical examination

Traumatic alopecia can be another manifestation of child abuse. Distinguishing characteristics of child abuse include signs of trauma such as scalp hematoma, tenderness and irregular outlines of localized hairloss. In addition, hair breakage and subsequent regrowth is typically at a more regular length in traumatic alopecia compared to trichotillomania.

Diagnosis confirmation

The differential diagnosis includes tinea capitis, traction alopecia (possibly from hairstyling or braids), trichotillomania, loose anagen hair syndrome and alopecia areata. Trichotillomania can be particularly difficult to distinguish from traumatic alopecia. Distinguishing characteristics of child abuse include signs of trauma such as scalp hematoma, tenderness and irregular outlines of localized hairloss. In addition, hair breakage and subsequent regrowth is typically at a more regular length in traumatic alopecia compared to trichotillomania.

NEGLECT

Neglect is the most common form of abuse and involves inattention to a child's nutrition, clothing, shelter, safety, medical care or education. Physical manifestations of neglect include subcutaneous wasting secondary to malnutrition, poor hygiene (often with dental caries or pediculosis capitits, multiple untreated injuries and dermatitis caused by avitaminosis (often diaper dermatitis).

SEXUAL ABUSE

The evaluation of sexual abuse requires an understanding of normal and abnormal pediatric genital anatomy. All girls suspected of abuse should undergo evaluation of the labia majora, labia minora, introitus and hymen for erythema, ecchymoses, abrasions or tears. In boys, the external genitalia must be evaluated for erythema, ecchymoses, abrasions, lacerations and bite patterns. Circumferential injuries to the shaft or glans penis are suggestive of abuse. The urethral meatus may also have lacerations, erythema and discharge.

Characteristic findings on physical examination

The majority of children referred for medical evaluation have normal exams. Only 5% of children reporting vaginal or anal penetration actually have an abnormal exam. The absence of physical findings is best explained by the theories that the physical abuse did not produce visible injury or that the anogenital region healed completely prior to exam. Two factors highly correlated with the presence of abnormal genital findings include a short time interval since the incident and a history of blood being reported at the time of molestation.

The oral cavity is a common site of sexual abuse in children and features suggestive of forced oral penetration include frenulum tears and bruising or petechiae on the hard palate.

Anogenital findings specific for abuse include:

Acute laceration of hymen (partial or complete)

Ecchymosis of hymen

Perianal lacerations extending into the anal sphincter

New scars in the posterior fourchette of the hymen

Absence of hymenal tissue (partial or complete)

Immediate dilatation of the anus in a knee-chest position (without a history of constipation, stool in the vault or neurologic disorder)

Purulent/malordorous discharge

Unintentional injuries to the perineum include straddle injuries, zipper entrapment, hair tourniquet and even seat belt injury. Straddle injuries can be differentiated from abuse since they are typically unilateral, superficial and involve the anterior portion of the genitalia, particularly the labia minora or urethra. A variety of dermatologic conditions that cause ulcers, erythema, friability or even bleeding of anogenital skin should be considered when sexual abuse is suspected.

Diagnostic confirmation

Dermatologic mimickers of sexual abuse include:

Lichen sclerosis et atrophicus

Non-specific vulvovaginitis

Seborrheic dermatitis

Atopic dermatitis

Contact dermatitis

Scabies or pinworms

Perinanal streptococcal dermatitis

Lichen simplex chronicus

Lichen planus

Psoriasis

Hemangiomas

Vulvar bullous pemphigoid

Behçet's disease

Urethral prolapse

Kawasaki disease

Lichen sclerosis et atrophicus is the most common skin condition mistaken for sexual abuse. The question of sexual abuse has been raised in about 77% of cases. About 7 to 15% of cases begin in childhood (most commonly between 3 and 7 years of age). The presence of hypopigmentation, atrophy and telangiectasias should help differentiate this condition from sexual maltreatment.

There are a few unambiguous diagnostic signs of sexual abuse present in only a minority of children. They include genital trauma (described above) and the detection of sexually transmitted infections. The presence of semen, sperm, prostatic acid phosphatase, serologic evidence of syphilis or HIV and a positive culture for gonorrhea are considered definite evidence of abuse when congenital acquisition and transfusion-acquired HIV are excluded.

Any age child disclosing sexual abuse should also receive screening for other sexually transmitted infections (STIs). All postpubertal adolescents need screening for STIs since 5% of adolescents have positive tests even without symptoms. Screening is typically low yield in asymptomatic pre-pubertal girls, but necessary if vaginal discharge is present. Only 0.8% of pre-pubertal girls will have positive tests. The US Centers for Disease Control and Prevention recommend testing for syphilis, gonorrhea, chlamydia, trichomonas, herpes simplex virus and HIV when indicated. Swab samples should be taken from the rectum, pharynx and urethra in addition to the vagina and/or cervix in females.

Sexually transmitted Infections include:

Possible abuse

Herpes simplex virus (HSV) Type I anogenital lesions

Condyloma acuminata in a child > 3-5 years

Probable abuse

HSV Type 2 (not perinatally acquired)

Trichomonas infection in a child > 1 year

Chlamydia trachomatis in a child > 3 years

Definite evidence of abuse or sexual contact

Gonorrhea (not perinatally acquired)

Syphilis (not perinatally acquired)

HIV infection (not perinatally acquired or via transfusion)

Evidence of HSV, condyloma acuminata, chlamydia or trichomonas infection indicates probable abuse in children over 3 years of age.

HSV can be spread via autoinculation or perinatally. Both HSV types I and 2 can be transmitted via sexual abuse, but HSV 2 is more likely. Recurrent herpes gingivostomatitis or herpetic whitlow argues against abuse. New genital lesions in children > 5 years with independent toileting are suspicious for abuse and should be reported.

Human papilloma virus is one of the most common sexually transmitted infections and the incidence of pediatric cases is increasing. Nonsexual acquisition is possible via vertical transmission at birth, hand contact during diapering, fomites and autoinoculation. Perinatal acquisition can have a long latency, but is less likely in children less than 3 years of age and sexual abuse should be considered. HPV DNA typing is not helpful in determining the mode of transmission.

When evaluating a child, history should include age of onset, history of maternal infection, personal and family history of verruca and an understanding of the child's social environment and caretakers. Prevalence of sexual abuse ranges from 4 to 91%. The AAD considers genital warts “suspicious” and recommends reporting to Child Protection Services (CPS).

Anogential molluscum contagiosum are common in children less than 5 years of age. They can be transmitted via autoinoculation, fomites or between individuals and are almost always a result of benign transmission. However, sexual transmission if possible and should be suspected in association with unusual behavior, absence of molluscum on non-genital skin and other signs of sexual abuse.

Expected results of diagnostic studies

Diagnostic studies include:

Skin examination

Complete skeletal survey (long bone, chest and skull)in all children under 2 years of age or any child with multiple or severe fractures

Computed tomography (CT) of the head if the child has altered mental status or head injury

Who is at Risk for Developing this Disease?

Certain children are more likely than others to be victims of abuse. Characteristics of abused children include:

Young age. The majority of abused children are between the ages of 1 and 12. Children under age 4 are at the greatest risk of severe injury and account for 79% of child maltreatment fatalities.

A history of abuse. An abused child has a 50% chance of recurrent abuse and a 10% chance of death if abuse is not detected at the initial presentation

Poor parent-child bonding. Children with learning disabilities, chronic illnesses, conduct disorders, mental retardation, history of prematurity or other handicaps.

Family structure. Single-parent families, adolescent parents. evelopmental challenges. In infants less than 18 months, inconsolable crying is a precipitating factor. In preschoolers, toilet training or a toilet accident may be a precipitating factor

Medical care history. Poor childhood record of immunizations, preventive care

What is the Cause of the Disease?

The most common perpetrators of child abuse, in descending order of frequency, include fathers, mothers' boyfriends, female babysitters and mothers. Parents are the perpetrators in 77% of child abuse fatalities. An estimated 90% of sexual abuse is committed by men and 70 to 90% of perpetrators are individuals known to the child.

Factors leading to an increase risk of abuse by caretakers include the following:

Parents were abused themselves

Parents' expectations are inconsistent with normal child development

Family disorganization, dissolution, violence among family members and lack of external support

Systemic Implications and Complications

The emotional and psychological sequelae of child abuse are devastating and require appropriate psychiatric counseling and support. Many behavioral disorders are often the result of childhood maltreatment.

Recognizing the cutaneous manifestations of child abuse may be challenging but is essential in making an accurate diagnosis. Errors of omission can lead to child fatality whereas errors of commission can cost the reputation of an innocent adult and cause familial turmoil.

Treatment Options

Aside from the greater issue of recognizing that child abuse occured, and reporting concerns to the proper authorities, immediate care must be given for any dermatologic injuries (burns, primary and secondary infections, etc) based on standard protocols for those disorders

Optimal Therapeutic Approach for this Disease

Recognition of child abuse, reporting, and evaluation are discussed in patient management. Dermatologic complications should be treated accordingly as they would be in the absence of child abuse. It is also important to consider getting the expertise of specialists, such as a geneticist, to consider evaluating disorders that may be difficult to distinguish from child abuse, such as osteogenesis imperfecta.

Patient Management

Recognition of abuse or neglect must be immediately reported to a state or local CPS agency.The national number 800 4-A-CHILD (422-4453) is available to help locate a regional department. In all states, professionals, including health care providers, mental health professionals, teachers, social workers, day care providers, and law enforcement personnel are mandated by law to report suspected child abuse or neglect. People reporting suspected child maltreatment in “good faith” are free from criminal and civil liability. It is important to remember that the duty to report only requires reasonable suspicion that abuse has occurred and not certainty.

If possible, a sexual abuse evaluation should be performed by an experienced examiner. All victims of child abuse should also be evaluated by a pediatrician and a mental health professional.

Unusual Clinical Scenarios to Consider in Patient Management

Remember that irrefutable physical findings of sexual abuse occur in less than 10% of cases and that it is “normal to be normal."

When a genital ulcer is evaluated, it is important to test for the herpes virus before concluding that a child has been abused. Other possible causes for ulceration include apthae or EBV.

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